Reflections in a Head Mirror

“Hi, you have reached the voicemail of George and Sue. Sue and I are not available right now, but if you leave a message after the tone, we will get back to you as soon as possible. Have a great day!”

A tone warbles on the other end. I pause, dumbstruck, for more than a second. George is my patient, but he has not been doing well over the past six months. After a portion of his tongue was removed, he underwent a combination of chemotherapy and radiation. His cancer is controlled, but his health, poor to begin with, has deteriorated. For the time being, he communicates primarily with gestures, writing, and an occasional spoken word. After some time at home with Sue, they both decided that he needed more intensive therapy and she needed some rest. He was admitted to a local rehabilitation facility to regain his strength.

“Hello, Mrs. Jones. This is Dr. Campbell. I was just calling to check up on you and see how things are going …”

There is a sudden click and I hear some fumbling at the other end of the line. Suddenly, she is talking.

“Hello, Dr. Campbell. This is Sue. I just came back from visiting George. He is looking better.” She spends some time going over his situation. He is frustrated, but, overall, he is adjusting to his new life and the regimen. His communication skills need a lot of work. They both hope his stay there will be brief. She thinks he is resting better. It is clear that she is.

“That is great! By the way, it was very interesting to hear his voice on the answering machine when I called …” Since I first had met him, he has always had difficulty talking. The voice on the machine, on the other hand, was clear and strong with no hint of the coming tongue cancer problems.

She laughs. “I suppose I should change the message on the machine. He made that recording last year, long before he got sick.” She pauses. “You know, I don’t even notice it when it plays. That is the way I remember him always sounding. That is the voice I have listened to for 45 years.” She laughs again, ruefully this time. “Besides, no one would understand him if he made a new recording now.”

I emphatically tell her the message is just fine. I don’t tell her that hearing his message on the machine having perfect articulation is more than a little spooky – somewhat akin to getting an e-mail sent from a friend who has died (because the family hasn’t removed his name from the account), or like getting junk mail and magazines forwarded from a dead relative’s home. The voice is unique. While we might be able to flip though pages of yellowing, faded photographs of friends and family irretrievably gone from us, rarely do we have the opportunity to hear their voices.

“Thanks for calling, Dr. Campbell. Talk to you again soon.”

“Good to hear your voice. Take care, Mrs. Jones.”

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This is exactly the kind of vignette I enjoy. It puts a human face on science; thanks for sharing. -   cardiogirl Thanks for sharing. its very inspiring http://healthrecord.blogspot.com

John R. Hogness, MD, was the first president of the Institute of Medicine. The IOM serves the country as an “aggressive, unbiased examiner of health care problems” within the National Academy of Sciences. It is an honest broker that tackles the biggest and most complex problems that medicine faces, proposes the difficult and rational solutions required to improve health care. By nurturing the IOM during its nascent days, Dr. Hogness likely shaped how we, as a country, will address health care public policy debates for years to come.

Dr. Hogness recently died; I loved the stories about him that were told and implied in his obituary. While serving as dean of the University of Washington Medical School, he spent two months showing, in a practical way, his belief in the value of rural medicine by substituting for a vacationing primary practice physician in Omak, WA. He saw patients, made house calls, and even completed an appendectomy when the surgeon became ill.

The article stressed that he believed that great physicians can be found both inside and outside of medical school practices. “There are turkeys everywhere, including academia,” he noted. I suspect he might have looked with disdain on the profusion of “Best Doctor” lists with their inherent biases against non-academic private practitioners.

After a professional career as a dean, provost, curriculum innovator, national leader, quality advocate, and visionary, he finished his calling where he began, as a physician. The article describes him as “a shy yet affable man … who used his sense of humor, a physician’s bedside manner, a diplomat’s skills, a flair for acting, and an administrator’s discipline.”

Pulitzer Prize winning author Wallace Stegner wrote in Crossing to Safety that “talent lies around us like kindling waiting for a match, but some people, just as gifted as others, are less lucky. Fate never drops a match on them.” As I read this short synopsis of his life, I was struck that not only were Dr. Hogness’s talents set on fire but that he nurtured his gifts and shared them willingly.

His life’s work will have an impact on all of our medical careers for generations to come; how remarkable that the vast majority of us will never know whose talents were ignited and fanned to bring us to where we are and could yet go in the future.

The New York Times obituary (NYT 07-10-2007 A21)

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Sounds like he might have been "the match" for many of those around him. - rlbates

My new patient had lost 30 pounds over the past couple of months because he could not swallow but was too proud to call his family. He had been growing progressively weaker and was only a shadow of what he had been; “He could walk through a harp,” we sometimes say. His breathing passage was getting tight. His family, who had not seen him for a few weeks, was alarmed. They finally reached him on the telephone and went to the house where he lived by himself. They all but dragged him to the local hospital.

A physician found a large cancer of the throat and immediately transferred him to us; we had gone to the operating room for a tracheotomy and placement of a feeding tube. Now he was stable.

It was time to discuss moving him back closer to his home for further care. As I walked into the room, I glanced at the two daughters, their husbands, and their kids. The scene was all too familiar: a concerned but estranged family with a lot of history and a dad who had absolutely no intention of getting any assistance from anyone.

He coughed. They scowled. I looked for a way to make a connection.

By chance, I glanced at the bulletin board in his hospital room where the family had tacked up an old photograph. I scanned through the faces of several smiling men wearing identical shirts and holding bowling balls. Their hairstyles and the faded image placed the picture in the mid 1980s – about 20 years ago.

“What’s this?” I asked. “Tell me the story.”

“Dad was in the National Bowling Championships in Las Vegas that year. His team did very well. He was one of their stars. That was one of the proudest moments of his life.”

I studied the image. I looked back-and-forth between the photograph and my patient. Sure enough, one of the smiling, well-muscled, healthy men had the same eyes as the man lying in the bed across the room. The years and the cancer had changed him. Now the bowling star had a gaunt face, wasted muscles, long gray hair, a scraggly beard, a new tracheotomy, and a disheveled appearance. It was clear that his days of controlling the spin on a 16-pound ball were behind him. I looked carefully at the photo and spotted packs of cigarettes in most of the bowling shirt pockets.

“That is absolutely terrific! Wow! What an accomplishment!”

My new patient beamed, his smile briefly lighting up the room. As he tried to say something, he coughed some more phlegm out of his tracheotomy tube.

He reached for a pen. In large letters, he wrote, “We were winners.”

As I studied the message he had written on the pad of paper, one of his daughters sighed and shook her head. “That was a long time ago, Dad.”

This blog, in particular The 5th of July post, was added to Grand Rounds, a weekly listing of the best of the medical blogosphere. The list is hosted on a rotating basis and thanks goes this week to Vitum Medicinus.

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Congratulations! This was much deserved. I enjoy your blog very much. - KM

For this task, I prepare but never rehearse.

Gathering my thoughts, I walk deliberately down the Day Surgery corridor. In a minute, I will walk through the door of my patient’s room and deliver the news that neither she nor her family ever wanted to hear again. The woman, who had been treated successfully a couple of years ago, has a new cancer. The biopsy today has confirmed the diagnosis.

As usual, I pause outside the door for a moment. Before I am finished with the imminent conversation, we will have confirmed the diagnosis, discussed the plan of attack, confirmed her upcoming appointments, and, possibly, explored some frightening topics. Experience tells me that she will remember few of the details.

In the moment before I slide open the glass partition and enter the room, I am flooded by the stories and faces of patients who have faced similar recurrences; they bang around in my head vying for attention. As I anticipate her thorny questions and concerns, I stock my memory bank with research information and words of encouragement as an archer might select arrows.

I walk into the room and sit down. Our eyes meet and I touch her hand. “What we found explains why you have had more pain recently,” I begin.

“Oh, my God!” Her voice trails off. Her husband, a husky, bearded man, reddens, stifling a sob. Their granddaughter, a quiet 10-year-old with a wide open expression, grasps her other hand. The woman struggles to clear her head and to pay attention.

The brief family discussion is familiar yet is still different from any other before or since. I remain as unambiguous and straightforward as possible. I intentionally maintain a sense of hope. I briefly cover the next steps and the treatment options. I encourage them to call anytime they need support. We will repeat this discussion almost word-for-word in a few days.

The dialogue is winding down. “What other questions do you have? What do you want to know?”  The patient and her husband shake their heads; they have exhausted their lists for the time being.

I turn to the granddaughter.  “And how about you, Brittany? Do you have any questions?”

She wrinkles her nose and regards me quizzically for a few seconds. Her mind had been far away. Finally, a question gels in her head and she wonders, “How long does it take to become a doctor?”

Her grandfather smiles and wipes his eyes. He shakes his large head. “You think you want to be a doctor?”

“Maybe.”

The mood has changed perceptibly. I reset my focus and spend a minute encouraging her to work hard in her classes. She nods and tells me how much she loves school. She understands.  

“Other questions? None today? We are going to get you through this together! Call, okay? See you next week.”

I grip everyone’s hand and head back to the Operating Room for the next case.  

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Wow, you are a very talented writer. I've only read a few posts, but I am intrigued and will be adding you as a bookmark. Keep writing! -   cardiogirl cardiogirl.diaryland.com

Headline: “Woman cured of throat cancer after licking Elvis stamp”

Many years ago, a colleague gave me a copy of an article from a tabloid. A woman with progressive swallowing and talking problems was, sadly, found to have throat cancer.

To boost her spirits, she listened to Elvis tapes and bought some of the brand new Elvis stamps. Shortly after paying some bills and using the new stamps, she noticed that she felt much better. "All of a sudden I could swallow again ... I couldn't believe it." A medical expert confirmed that her cancer had completely disappeared! He was quoted in the tabloid as saying, "Medically speaking, her sudden total recovery cannot be explained."

The patient gave credit to the King. "It was Elvis sending his love from the spirit world." It certainly was an inspiring story.

Unfortunately, these types of Elvis-related medical cures are not common. Perhaps, there are some reasons for this: 

• Elvis stamps are all but out of circulation now. The stamp pictured in the article sold for 29¢, which has not been the first class postage rate since 1995.
• No one licks stamps anymore. What if someone could be cured of throat cancer by licking one of the current 41¢ self-adhesive Liberty Bell stamps? We would never know.
• Possibly, the cure was possible only because the Elvis stamp got close to the cancer during the actual licking process. What if the person had cancer of a different part of the body? How would she have needed to moisten the Elvis stamp to have an effect on, say, a brain tumor?

Dr. Sherwin Nuland, in the epilogue of his book, The Mysteries Within, writes about two different approaches to understanding the “Truth.” Empiricism, which is embraced by “traditional” Western medicine, insists on data. In Empiricism, Truth can change when enough data show that a prevalent understanding is faulty. Rationalism, on the other hand, fits any available data to a preconceived image of what the Truth is. In this view, Truth is fixed and no amount of data can alter it. I suspect that most adherents to the “Elvis stamps can cure throat cancer theory” would tend to fall into the Rationalism camp.

The Elvis stamp story provides an extreme example, of course, but frequently I am handed printouts on various dietary supplements and “cancer cures” that have never been empirically tested yet have unshakably loyal supporters. The discussions I have had about these products satisfies no one. Sometimes, it appears that Empiricism and Rationalism are very, very far apart.   

My training and convictions put me firmly in the Empiricism camp. Still, would it be okay to keep a few Elvis stamps around, just in case?

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Excellent post. Elvis has been credited with many wondrous things, but I have not heard of this throat cancer cure.   I think some of this comes down to the idea of "belief." We all believe things that are not scientifically shown. When we say "I believe the Colts will win the Super Bowl" (or perhaps the Packers, in your case), that is meant more as just "I feel that they will." This woman can very well believe that the stamp did it and not be irrational if she accepts other possibilities. The problem comes when people believe this stuff despite contrary data or other more plausible explanations. They believe the facts to be scientific, when in fact they are nothing more than opinion. - Rob Magical thinking is common, especially for those with diseases that have no known cure. It is understandable that patients do not want to accept their diagnosis and instead build false hopes on implausible "cures." I might also do this if I were terminally ill. However, it is dishonest to feed false hope, and it opens the door to snake oil and its salesmen. Some physicians feel that it's kinder not to disabuse people of their magic cures (that there is a psychological benefit to having hope in a placebo) - and I can respect that. However, if the patient is spending money (perhaps their life savings) on snake oil - or putting off getting their affairs in order or taking trips - all for a treatment that has no possible benefit - I would want to have a frank discussion with them. Many times we can talk through the feelings that are driving the patient towards Elvis stamps - and that discussion has more therapeutic value (in my opinion) than the stamps ever will. - Val Jones

It was the 5th of July in the Emergency Department many years ago. A 10-year-old boy was crying, embarrassed, and scared. He was hurt, but in the long run, everything was going to turn out fine. It was a moment I have not forgotten. I suspect he remembers it even better than I do.

At the time, fireworks were still allowed within city limits. Young kids, particularly boys, looked forward to the 4th of July by accumulating paper packs of Black Cat firecrackers. As kids, we would untangle the fuses and pull one of the firecrackers from the package. A friend would light the fuse and we would hold the firecracker as long as we dared. It was, of course, a completely stupid thing to do; occasionally, someone would wait too long and be rewarded with ringing ears and buzzing fingertips. All of our friends would think it was absolutely hilarious. If I had ever caught my own kids doing the same thing, I would have gone crazy.

So, back to our story … On this particular 5th of July, the 10-year-old boy had gone to the park the morning after a group of older kids had set off hundreds of the small firecrackers. The night had been dry and he found a couple of dozen that were intact but had no fuses. For some reason, he decided that it would be really cool to set them off all at once. Even better, he wanted to have them shoot up into the air. He looked around and found the metal pipe the older boys had used the night before to launch bottle rockets. Awesome! The pipe, he believed, would send the explosion high up into the sky.

He carefully jammed a piece of paper in one end of the pipe and then packed in all of the loose firecrackers he could find. He tried to figure out how best to steady the pipe. In his mind, he pictured an amazing, canon-like display of pyrotechnics.

He took a match, lit the paper, and decided which direction he wanted to aim the blast, steadying the pipe BETWEEN HIS LEGS! The firecrackers, obeying the laws of physics, sent hot gas, smoke, and flaming debris out both ends of the pipe simultaneously. His shorts caught fire. The results were not pretty, but he would eventually recover. He was fortunate.

Since that day, the image of the damage even those little firecrackers can inflict has been joined in my mind by images of the potential consequences of driving intoxicated, riding a motorcycle and smoking cigarettes. Being involved, even peripherally, in the care of patients who have made bad or unfortunate choices has made me risk averse.

It is more than just knowing that some things are dangerous ... I also have seen and remembered the outcomes. I have worked in the Emergency Department, followed patients in the Neuro Intensive Care Unit, and been present at the hospice bedside. I have watched the families. The lessons sting and they stick. The smell of scorched cotton shorts lingers.

St. Teresa of Avila pointed out: “It is extraordinary what a difference there is between understanding a thing and knowing it by experience.” Sometimes, the experiences we stumble across in a hospital can shake us to our very bones.

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I'm saving this blog for my unborn grandchild. It's never too early to assemble an arsenal of wisdom. - Mary Brawley